Body dissatisfaction, drug use, and associated factors among adolescents in three Brazilian cities

Abstract Objective: analyze the association between drug use and body dissatisfaction among adolescents in three Brazilian cities. Method: cross-sectional study, using a nested randomized controlled trial to evaluate the drug use prevention program #TamoJunto2.0 of the Ministry of Health in Brazilian schools. The sample consisted of 5,213 students from 73 schools in three Brazilian cities. The outcome body satisfaction was analyzed using the Stunkard scale and the explanatory variables were drug use and sociodemographic data. Results: the adolescents were between 12 and 14 years old; about 69.9% of them reported body dissatisfaction, and 35.67% used alcohol in the previous year. Dissatisfaction due to overweight was higher among girls (41.5%) and dissatisfaction due to underweight was higher among boys (33.1%). Adolescents who used marijuana were 39% (OR=1.39) more likely to feel dissatisfied due to underweight and being a girl increased the chances of feeling dissatisfied due to overweight by 24% (OR=1.24). Conclusion: the levels of body dissatisfaction deserve attention in hebiatric nursing care and reinforce the importance of educational strategies addressing body image and drug use, relating them to the various subjective attributes that can affect the health of adolescents, whether in the community or at school.


Introduction
Body dissatisfaction in adolescence refers to a divergence in the perception of the real body and the ideal body, characterized by a negative view of oneself (1) , which can have implications to physical, mental and social well-being in this accelerated phase of development (2) .
Some factors, such as physical inactivity, unprotected sex, overweight, eating disorders, alcohol consumption, smoking, and drug use may be related to body dissatisfaction in adolescence, which may lead to irreparable health outcomes in adulthood (2)(3) . Adolescents who face changes in the perception of their body image are prone to the consumption of psychoactive substances as strategies to relief and protection against stress, anxiety and anguish (4) .
The use of licit and illicit drugs is a growing concern in several countries, with alcohol and marijuana being the most consumed drugs in the world (5) . In Brazil, the National School Health Survey (PeNSE) (2019), which is the largest school survey ever conducted, shows that 63.3% of students said they had already consumed alcohol, and more than 22.6% had tried smoking. Among the illicit drugs, the use of marijuana prevailed (6) ; and in contrast to national indices that indicate a reduction in smoking in Brazil, an increasing use of electronic cigarettes and hookahs was observed (7) .
In addition, the adoption of unhealthy behaviors and without proof of safe efficacy for weight control (8)(9) may be associated with the use of cigarettes and marijuana and body dissatisfaction (10) .
The literature shows evidence of a strong association between body dissatisfaction and use of psychoactive substances, especially among female individuals (11)(12) . This relationship of non-acceptance of the body may also be related to the different sociocultural requirements in body standardization, making it difficult to accept the diversity that differs from this established model (13) . The relationships between body image, culture, body identity, media standard, and the contextualization of these factors in time and space are complex, affecting individual behavior in search of the beauty standard (14) .
In view of the above, the level of body satisfaction and its related factors deserve attention in adolescence as a public health and mental health problem (2)(3) , and the literature has few studies that analyze the association between body image and abuse of substances, such as marijuana, inhalants, weight-loss drugs, and the practice of binge drinking (BD), mainly performed by nurses.
Studies on body satisfaction are usually produced in high-income countries; then, an important gap is observed in knowledge about adolescents in Latin America, a region with many social and economic differences and cultural factors that influence body appreciation (15) , in addition to the context of different socioeconomic classes. In Brazil, a continental country, there are different ways of "being a teenager," mainly in the study population of teenagers from different regions.
With a better understanding of the factors related to body dissatisfaction among adolescents, it is possible to identify situations of vulnerability and guide specific public actions and policies to prevent risk behaviors related to body image, whether in drug use or other negative health outcomes. In this context, the possibility of nurse's actions is highlighted, as well as the strengthening of government programs that allow a focus on adolescent health in primary care and other levels of health care. Therefore, this study aimed to analyze the association between drug use (smoking, over-the-counter weight-loss drugs, marijuana, inhalants, cocaine, alcohol, and excessive alcohol consumption) and body dissatisfaction among adolescents in three Brazilian cities.

Study design
This study used a sample of a randomized controlled trial (RCT) whose initial objective was to evaluate the effectiveness of a drug use prevention program for 8th grade adolescents (16) . Then, the RCT with two parallel groups (intervention and control) was conducted with among 8th grade students from public schools

Participants
The sample consisted of 5,213 students from 205 classes of 8th graders (16) . Participants with some type of reduced cognitive or physical capacity to fill out the instrument had a trained researcher to help them in a private place at the school. The adolescents were identified by a confidential code and, after filling the instrument, they placed it in an unidentified envelope that was sealed in front of them.
The school acceptance rate was 93.6% (78 schools were invited) and, considering the enrollment records, 6,993 students were expected in the participating classes; however only 23% absences were reported, related to classes that no longer existed at the time of the study or were grouped together due to school renovation, or the adolescents were no longer attending the institution.
Only 123 students refused to participate, generating a refusal rate of 2.2%. More information about the study design and sampling procedures are described in previously published articles (16)(17) .

Data collection/instrument
Data were collected from February to March 2019 using an anonymous self-report questionnaire, applied by trained researchers in the classroom, without the presence of the teacher or another school employee.
The questionnaire was adapted from the instrument previously developed and tested by the European Drug Abuse Prevention Trial (EU-Dap) and used in previous studies assessing the effectiveness of Unplugged (18) .
A version translated and adapted to Brazilian Portuguese (19) was used, with some questions replaced by items from two questionnaires widely used in several Brazilian studies that assess students: a questionnaire from the World Health Organization (WHO), used in the VI Brazilian Survey on Drug Use among Students (20) , and the questionnaire of the National Student Health Survey, used by the Brazilian Ministry of Health (21) .
The final questionnaire used in this study has been validated in Brazil (22) . It has modules addressing sociodemographic data and presents information about when (month, year, and age) the adolescent used the following drugs: alcohol, smoking, marijuana, inhalants, cocaine, amphetamines, benzodiazepines, and crack cocaine; practice of binge drinking (consumption of 5 or more alcoholic drinks in a short period), as well as questions assessing body satisfaction.

Study variables
The outcome variable "body satisfaction" was analyzed through two questions about body perception and satisfaction based on the Stunkard scale, an instrument that has been widely used with adolescents (23)(24)  to underweight (plus value), or dissatisfied due to overweight (minus value) (23) .
The explanatory variables analyzed in the study were: 1) Drug use by adolescents (yes or no) in the last year: smoking, over-the-counter weight-loss drugs, marijuana, inhalants, cocaine, alcohol and excessive alcohol consumption (consumption of 5 or more alcoholic drinks over a two-hour period); 2) Sociodemographic data: sex, age, city, and socioeconomic status (the latter was evaluated using the scale of the Brazilian Association of Market Research Companies (ABEP) (25) , which takes into account the education of the head of the family and the goods and services consumed, with scores ranging from 1 to 100 or categories from A to E; higher scores indicate better economic Rev. Latino-Am. Enfermagem 2022;30(spe):e3663.
status, and socioeconomic classes are ranked A (highest) to E (lowest). According to ABEP, classes D/E may appear grouped. All variables used in this study were collected in the beginning of the study (baseline) and, therefore, were not randomized or influenced by the intervention.

Data treatment and analysis
Analyses were performed using weighted data to correct for uneven probabilities of sample selection.
The sample weights considered school as the main sampling unit, with stratification by city, total number of students expected in each class, students present on the day of the analysis, and total expected universe in each municipality according to the national registry (INEP). For descriptive statistics of weighted percentages (% by weight), Stata 16 was used, with svy commands.
To assess the agreement between real self-image and ideal self-image, this study determined correspondences between silhouette categories and each nutritional status category: underweight (silhouettes 1, 2, 3), eutrophy (silhouettes 4, 5, 6), and overweight (silhouettes 7,8,9). The agreement between real self-image and ideal self-image was assessed using Kappa statistics in Stata 16.
As a large amount of data related to body dissatisfaction was not provided by the adolescents when answering the form, missing data were imputed in Mplus version 8.0 by multiple imputation using a sequential imputation approach, that is, multiple imputations were performed using the Bayes estimation and an unconstrained variance-covariance model to assign the missing values (26) . The following variables were used in the unconstrained model: group, school, city, sex, age, drug use (alcohol, excessive consumption of alcohol, smoking, inhalants, marijuana, cocaine, and weight-loss drugs), and ABEP classification. Fifty sets of imputed data were generated.
Then, univariate and multivariate multinomial logistic regressions were performed in Mplus 8.0, with the explanatory variables (drug use, city, ABEP score, sex, and age) affecting the outcome measurement (body satisfaction). An initial multivariate regression model was considered, including the explanatory variables with a value of p≤0.20 in the univariate regression, and then a retroactive procedure was manually performed to remove the explanatory variables with p>0.05, eliminating the variable with the highest p value, one by one, in order to check for correlation between the explanatory variables (27) and thus obtain a final model for each response variable (dissatisfaction due to underweight and dissatisfaction due to overweight), the respective odds ratio (OR), 95% confidence interval (CI), and p values. The significance level was 5%.

Ethical aspects
This study observed all ethical precepts of Resolution      (Table 3).

Discussion
The most relevant finding of the study is that data refer to a representative sample of adolescents, an initial phase of this stage of life, from a middle-income country, showing a high prevalence of body dissatisfaction.
In general, gender and socioeconomic class are two factors highly associated with body dissatisfaction, but with opposite effects, depending on the type of dissatisfaction.
The results highlight prevalence of dissatisfaction due to overweight, showing a trend also found in other studies about body dissatisfaction, ranging from 44% to 83% (dissatisfaction due to overweight) and from 1.7% to 37% (dissatisfaction due to underweight) (21,(28)(29) . Some factors can influence this problem among adolescents, such as sex, anthropometric measurements, unsatisfactory meal pattern, relationship with peers (third party provocation), and social media (30) .
In Brazil, however, this topic deserves attention among adolescents, since the impact of body dissatisfaction can lead to a reduction in quality of life and affect biopsychosocial aspects, such as weaknesses of mental health, eating disorders, use of anabolic steroids, and even higher chances of suicidal thoughts and ideation (31)(32) .
For the actions of school nurses, this information is valuable to promote adolescent care management.
Most adolescents were dissatisfied with their body due to overweight, especially girls. In agreement with these findings, Chinese adolescents also prefer smaller bodies (33) , and other studies in Brazil have identified that while boys overestimate their body image, girls want smaller silhouettes (28,(34)(35) . Clear influence of social media on the body image was observed, generating, in most cases, dissatisfaction due to a desire to have an ideal physical standard (female thin body and male muscular body), causing fear of possible rejection and psychological distress (36)(37)(38)(39) .  (40) .
Identity construction is noticeable in adolescence, and in this period adolescents may suffer social pressure for behaviors that are dangerous to health. Then, it is important to learn about the context of vulnerability inherent to this phase, emphasizing that body dissatisfaction is more common among girls, as they are more subject to the alcohol use and smoking when they have negative images of themselves (41) .
In addition to the differences between genders, our findings point to influences of the socioeconomic status, as the chances of dissatisfaction due to underweight are lower among higher social classes, while dissatisfaction due to overweight is higher. One explanation is that lower socioeconomic classes show higher proportion of adolescents who want larger silhouettes, a fact that highlight the vulnerability of this population, particularly regarding food insecurity of families (42)(43) .
Another important aspect is that eating patterns and physical activity practice are associated with body dissatisfaction as adolescents usually adopt unhealthy diets, and/or do not practice physical activity properly (44) or skip meals (45) . In Brazil, regardless of the region, the eating habits of adolescents mostly involve fatty foods, fast foods, foods with sugar, disregarding the importance of nutrients (46) .
Regarding body dissatisfaction due to underweight, this study showed that adolescents who used marijuana were more likely to present this condition. Then, the literature (47) showed that body dissatisfaction In addition, body dissatisfaction is directly related to the consumption of alcohol in life (current and excessive consumption), as the association is common, especially regarding excessive consumption, which may be a coping mechanism or a weight change strategy (5) .
In relation to smoking and use of inhalants,  (6) . In adolescence, inhalants impair growth, affect metabolism and food intake, change food preferences and glucose metabolism and skeletal muscle adiposity, in addition to predisposing users to withdrawal syndrome, which is directly related to body image (50) .
Then, the results of our study provide evidence to adolescent health professionals to consider body dissatisfaction as a public health problem, and it is important to promote early interventions and prevent risky behaviors. In Brazil, the culture related to alcohol consumption is so permissive in adolescence that, when combined with poor control in the sale of alcoholic drinks, requires investments in studies to assess these vulnerabilities. in European countries (18) .
Study limitations include the fact that it covered only three Brazilian cities, so it should be analyzed with caution regarding the representation of the Brazilian population and its great diversity in the geographic area. In addition, the questionnaires were applied in Rev. Latino-Am. Enfermagem 2022;30(spe):e3663.
a school environment, which can be influenced by the environment and peers, and even if teachers were not present in the classroom during data collection, it could suggest some type of recrimination or judgment in the imagination of adolescents.

Conclusion
Our study showed a high prevalence of body dissatisfaction in adolescents who have just started this phase, with an emphasis on dissatisfaction due to overweight, presented in different ways when comparing boys and girls, and different social classes.
Then, this study may contribute to reflections of health and education professionals on the implementation of educational health care actions addressing body image, relating it to various subjective and behavioral attributes that can affect the health of adolescents, whether in the community or school environment.
In addition, public prevention programs and policies that encourage positive perceptions of self-image and better self-acceptance among adolescents must have special attention, considering the specificities of each individual, in order to promote healthy youth and minimize negative outcomes, such as abuse of alcohol and other drugs.